INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 16, 2010 through August 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 24, 2010.
|
Plan of Correction
|
704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
|
Observations
Based on the review of the facility's staffing summary report, personnel records and a interview with the facility director, the facility failed to ensure that the clinical supervisor meet at least one of the following groups in one of three clinical supervisor records reviewed.
The findings include:
Twenty-four personnel records were reviewed on August 11, 2010 through August 16, 2010. Three clinical supervisors records were reviewed, #3, 4 and 5. Employee #5 had the required degree, Bachelor, but did not have the required 3 year clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
|
Plan of Correction
The Staff Member not meeting the qualifications for Clinical Supervisor was released from his duties on August 27, 2010.
Effective immediately, before a Clinical Supervisor or any employee is hired, the Program Director will review all information provided to ensure that the candidate meets the clinical experience and degree requirements. The Department of Human Services will be responsible for verifying work history and degree. After all information has been verified the Program Director and the Department of Human Services will make the final decision to hire, under the supervision of the Vice President of Behavioral Medicine. This protocol will be followed with all new hires and will be effective immediately. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Twenty-four personnel records were reviewed on August 11, 2010 through August 16, 2010 and the staffing requirements facility summary report was reviewed on August 11, 2010 through August 12, 2010. There was no documentation of HIV/AIDS or TB/STD training in five employee records. Of the five, one was to have HIV/AIDS and TB/STD training within the first year of employment and the rest was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #9 was hired December 8, 2008 and was required to have HIV/AIDS & TB/STD training by December 8, 2009. There was no documentation of HIV/AIDS training in the employee's record as of August 16, 2010.
Employee #21 was hired November 12, 2007 and was required to have HIV/AIDS & TB/STD training by November 12, 2009. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #22 was hired May 12, 2008 and was required to have HIV/AIDS & TB/STD training by May 12, 2010. There was no documentation of HIV/AIDS training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #23 was hired October 8, 2007 and was required to have HIV/AIDS & TB/STD training by October 8, 2009. There was no documentation of TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #24 was hired October 15, 1985 and was required to have HIV/AIDS & TB/STD training by October 15, 1987. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
|
Plan of Correction
The New Employee Orientation will be modified to include HIV/AIDS and First Aid training along with the TB/STD and CPR training in order to ensure that all new hires obtain the DOH mandatory training requirements. The infection disease department will be responsible for providing HIV/AIDS and the education department will be responsible for providing First Aid. The modification will take place by November 2010.
By December 31, 2010 all current staff who is not compliant for training will receive the DOH mandatory training.
The Program Directors and the AVP or nursing will be responsible for ensuring that all staff has obtained required training. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2009 training year in two of fifteen personnel records where due.
The findings include:
Twenty-four personnel records were reviewed on August 11, 2010 through August 16, 2010. Five employee records represented the counselors who were required to have obtained 25 hours of training for the 2009 training year based on the hire dates, #6, 7, 8, 9 and 10.
Employee #9 was hired 12/8/08 and was required to have obtained 25 training hours for the 2009 training year. Employee #9 only had 10 hours of training for training year 2009.
Employee #10 was hired 1/18/09 and was required to have obtained 25 training hours for the 2009 training year. Employee #10 only had 10 hours of training for training year 2009.
|
Plan of Correction
Counselors have been reminded that it is their responsibility to complete 25 hours of training per year. The Program Director and the Clinical Supervisors will schedule and monitor all trainings to ensure compliance. The Progam Director will conduct quarterly reviews of the counselor's training plans to ensure hours are being met. All complete trainings will require a certificate of attendance with the date and hours of training. The counselor will complete a training evaluation to submit with the certificate. Full compliance will be achieved by 12-31-2010. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a tour of the facility ' s physical plant, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A tour of the facility's physical plant was conducted on August 25, 2010 at approximately 11:00 AM. A portable space heater was observed in counseling office #233.
|
Plan of Correction
The space heaters were immediately removed from the premises. The Staff member was reminded of regulations regarding the space heaters. The Clinical Supervisors will monitor compliance with this regulation on a ongoing basis. The program will be in compliance immediately. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
The facility fire drill record did not include any record of a fire drill for June 2010.
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building including the Goldman Clinic.
The staff person questioned confirmed that there was no documentation of a June 2010 Fire drills, nor were there any observation sheets completed for December 31, 2009.
|
Plan of Correction
As of September 13, 2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Division of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building including the Goldman Clinic.
The fire drill conducted on January 18, 2010 did not identify the exit route.
The fire drill record of February 25, 2010 only contained documentation for the ninth floor of the Tower building.
The fire drill conducted on April 6, 2010 did not include the number of participants.
The staff person questioned confirmed the findings.
|
Plan of Correction
As of September 13, 2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Division of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation to include the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions in fourteen of seventeen client records reviewed.
The finding includes:
Seventeen records were reviewed on August 17, 2010 through August 18, 2010. Psychosocial evaluations were required in Seventeen records reviewed.
Client records #1, 2, 3, 4, 5 and 7 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records #8 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impression.
Client record #9 failed to document the client ' s problems and needs, support systems and coping mechanisms.
Client records #11 failed to document the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client records #12 failed to document the client ' s problems and needs, assets/strengths, coping mechanisms and negative factors that might inhibit treatment.
Client records #16 failed to document the client ' s problems and needs, assets/strengths, support systems and negative factors that might inhibit treatment.
Client records #17 failed to document the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Also, client record #6 failed to have documentation of the clients psychosocial evaluation in record reviewed. Per the facility's policy and procedure psychosocial evaluations will be completed within 30 days of admission. Client record #6 was admitted on 3/30/10.
|
Plan of Correction
The Director of Outpatient Psychiatry will develop three hour training sessions on completing psychosocial evaluations and will provide the training to all clinical staff by November 30, 2010.
A psychologist from the Outpatient Department will conduct random reviews of evaluations and meet with clinical staff to review case formulations/evaluations for the next 90 days.
The Clinical Supervisors will review three cases per month of each clinician for the next 90 days, focusing on psychosocial evaluations.
Ongoing monitoring will be conducted by the Clinical Supervisors and full compliance will occur by December 31, 2010. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained seventeen of seventeen records reviewed.
The finding includes:
Seventeen records were reviewed on August 17, 2010 through August 18, 2010. An informed and voluntary consent from the client for the disclosure of information was required in all seventeen records reviewed.
In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, the release forms disclosing information to an insurance company and to an emergency contact did not include a statement informing the client of his right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consents in writing.
An interview with the facility director was conducted on August 18, 2010. The facility director confirmed that the release forms stated the client must revoke the consents in writing.
|
Plan of Correction
The consent to release information will be revised to include the statement: You have the right for verbal or written revocation of the consent to release information. All clients will be informed of their rights. All previous forms will be removed and replaced with the updated version. The change will be completed by the Director of Patient Access and Program Director of Goldman Clinic with the approval of the Vice President of Behavioral Medicince.
Once the form is updated, the Program Director and Supervisors will meet with all active clients to review and have them sign the new form. Full compliance will be reviewed by November 30, 2010. |